Case 1: Perfusion Challenges Sahil A. Parikh, MD, FACC, FSCAI - - PowerPoint PPT Presentation

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Case 1: Perfusion Challenges Sahil A. Parikh, MD, FACC, FSCAI - - PowerPoint PPT Presentation

Aug 19, 2023 462 likes •713 views

SCAI 2019 May 22, 2019 Case 1: Perfusion Challenges Sahil A. Parikh, MD, FACC, FSCAI Associate Professor of Medicine Director, Endovascular Services Center for Interventional Vascular Therapy New York-Presbyterian Hospital Columbia

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SLIDE 1

SCAI 2019

May 22, 2019

Case 1: Perfusion Challenges

Sahil A. Parikh, MD, FACC, FSCAI

Associate Professor of Medicine Director, Endovascular Services Center for Interventional Vascular Therapy New York-Presbyterian Hospital Columbia University Irving Medical Center Columbia University Vagelos College of Physicians and Surgeons

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SLIDE 2
  • Grant/Research Support
  • Consulting Fees/Honoraria
  • Advisory Board
  • TriReme Medical, Shockwave Medical,

NIH, Surmodics, Silk Road Medical (CEC); Boston Scientific (DSMB)

  • Terumo, Abiomed
  • Abbott, Boston Scientific, Medtronic, CSI,

Philips Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company

Disclosures

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SLIDE 3

Perfusion Challenges

  • 91 year old man
  • Former smoker, HTN, HL
  • CAD s/p CABG
  • Prior GIB
  • Rest pain in bilateral legs x 2-3 years
  • Two months prior – bilateral LE wounds
  • Right leg wound healed
  • Left leg – heel wound (1cm) and L medial malleolar ulcer
  • Currently living alone with little help
  • T:36.6 HR: 75 BP: 131/65
  • RR: 17 SpO2: 100%
  • Gen: NAD
  • Heart: RRR S4s1 s2
  • Chest: CTA &P
  • Abd: Soft nt nd, no bruit
  • Extr: warm, trace edema B/l, + femoral

bruits bilaterally, Doppler monophasic DP/PT bilaterally

  • L heel 1cm shallow ulcer and L medial

malleolar venous appearing ulcer

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SLIDE 4

Patient MB

SH

  • Quit smoking 20 years ago
  • 50+ pack year history
  • Now using wheelchair, previously walker
  • WBC 8.1
  • Hgb 10.6
  • Hct 31.0
  • Cr 0.9
  • INR 1.1
  • Plt 212

Meds

  • ASA 81 mg daily
  • Atorvastatin 20 mg daily
  • Losartan – HCTZ 50-12.5 mg daily
  • Terazosin 2 mg daily
  • Pantoprazole 40 mg daily
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SLIDE 5

ABI/PVR

FINDINGS: Resting: RIGHT LEFT Brachial 165 mmHg 162 mmHg Thigh 95 mmHg 85 mmHg Calf 89 mmHg 112 mmHg DP 69 mmHg 73 mmHg PT 0 mmHg 94 mmHg Toe 25 mmHg 35 mmHg DP ABI 0.42 0.44 PT ABI 0.00 0.57 TBI 0.15 0.21

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SLIDE 6

Doppler U/S

FINDINGS: Right Right Left Left ARTERIES Velocity Waveform Velocity Waveform Aorta 91.8 cm/s Biphasic Common Iliac 194.0 cm/s Monophasic External Iliac 119.0 cm/s Monophasic Common Femoral 234.0 cm/s Continuous 88.7 cm/s Triphasic Profunda 17.0 cm/s Biphasic 113.4 cm/s Triphasic Superficial Femoral (prox) 68.0 cm/s Continuous 122.0 cm/s Continuous Superficial Femoral (mid) 170.0 cm/s Tardus/Parvus 243.0 cm/s Continuous Superficial Femoral (distal) 37.0 cm/s Tardus/Parvus 41.5 cm/s Continuous Popliteal 56.0 cm/s Tardus/Parvus 48.9 cm/s Continuous TP Trunk 70.9 cm/s Tardus/Parvus 9.0 cm/s Tardus/Parvus Anterior Tibial 16.6 cm/s Tardus/Parvus 13.0 cm/s Monophasic Posterior Tibial 0.0 cm/s Occlusion 49.6 cm/s Tardus/Parvus Peroneal 41.0 cm/s Tardus/Parvus 0.0 cm/s Occlusion

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SLIDE 7

Diagnostic Angiogram

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SLIDE 8

Diagnostic Angiogram

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SLIDE 9

Runoff

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SLIDE 10

Now what?

  • What access?
  • What vessels will be treated?
  • Are patients with venous insufficiency treated differently?
  • How do we cross the CTO of the SFA and PT?
  • What definitive therapies are needed?
  • How do we define success?
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SLIDE 11

Wire Loop Crossing

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SLIDE 12

Subintimal Balloon

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SLIDE 13

Outback

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SLIDE 14

IVUS

IVUS shows deep subintimal position with dissection flap. True lumen near popliteal

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SLIDE 15

Shockwave 1

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SLIDE 16

Shockwave 2

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SLIDE 17

Post Shockwave/Balloon

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SLIDE 18

Post PTA

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SLIDE 19

Peroneal/PT

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SLIDE 20

Post-DCB Angioplasty Angiography

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SLIDE 21

Final angiography after Supera Stents

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SLIDE 22

Final Angios

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SLIDE 23

Intervention Summary

  • R CFA Access with 7F crossover access
  • CTO crossing, Outback re-entry
  • Dilation with PTA and Shockwave
  • DCB and tibial PTA
  • Supera Stents from pop-mid-SFA
  • Restoration of palpable pulse
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SLIDE 24

Epilogue

  • L heel wound almost healed in 6 weeks
  • L malleolar venous ulcer improved with compression and wound

care

  • L ABI 0.95. No rest pain
  • R ABI 0.48. No rest pain.